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Health inequality: importance of the life course Moving from description to explanation

Importance of ‘rainbow model’ Acknowledges that health inequality occurs in a complex context— “Contextual-systems model” Causes may act proximally or distally Need to add longitudinal perspective Rainbow encourages us to look for resilience factors as well as risk factors Look at responsibility of policies

What are the causes of health inequality? Need to understand causes in order to have effective policies Also, health inequality offers aetiological clues, even if you are not interested in policy at all

Four major approaches to explaining health inequality “Selection” “Material” “Behavioural” “Psychosocial”

HEALTH SOCIAL POSITION DIRECT SELECTION

Personal characteristic “x” HEALTH SOCIAL POSITION INDIRECT SELECTION BEHAVIOURS

Indirect selection “Personality” factors are set early in life ?genetics; ?parental care …. These then are the ‘causes’ of social position They also influence health related behaviours Health behaviours ‘determine’ health No direct causal link between adult social position and adult health

Indirect selection or life course processes? Merit of this approach is that it can only be tested in longitudinal research Up to now, not many studies have done this Seems to be a complex mixture of ‘risk’ and ‘resilience’ over time

Cognitive function at 8 years and mortality up to age 54: men born in 1946 Permission granted from International Journal of Epidemiology, Vol 33(2), Kuh et al, Childhood cognitive ability and deaths up until middle age, pp , Copyright 2005 with permission from Oxford University Press

Developmental contextual model of the development of inequality in psychological health from birth to age 33 in men and women born 1958 Permission granted from Social Science and Medicine, Vol 57, 2003, Schoon et al, Socio- economic adversity and psychosocial adjustment: a developmental-contextual perspective p , Copyright 2005 with permission from Elsevier

Material explanations Industrial hazards Dietary inadequacy Accidents at home, work and on road Area pollution Housing inadequate for climatic conditions

Morris et al. Costs of a healthy life Healthy food = £14.05 p.w. Heating = £5.41 p.w. Clothes and shoes £10.00 p.w. Lodging = £46.80 Social participation = £38.00 Total is about the same as UK Minimum Wage but far more than benefit level Source: Morris et al JECH 2000

Cost of a healthy life Biological necessities (food, clothing, heat) only make up the minority Major costs are social participation and lodging These 2 are determined by wider social forces No such thing as a ‘pure material’ explanation

Amartya Sen’s “capability” explanations Affordability of biological necessities depends on the costs of social participation “Relative deprivation in the space of incomes can yield absolute deprivation in the space of capabilities. In a country that is generally rich, more income may be needed to buy enough commodities to achieve the same social functioning, such as ‘appearing in public without shame’. The same applies to the capability of ‘taking part in the life of the community’”

Material and psychosocial hazards accumulate in the life course “Social reproduction” Less advantaged family background is linked to worse educational results Education is strongly linked to social class in adulthood Social class influences risks e.g. poor housing, low income, unemployment, job insecurity, low work autonomy

Unemployment 12+ months by father’s social class at birth Odds ratio for 12+ months’ unemployment Adj. crowding, education, region,height at 7, BSAG, parents’ heights Father’s social class Father’s social class Journal of Epidemiology & Community Health, 1996, 50: , reproduced with permission from BMJ Publishing Group

Economic status 1971 and 1981 by semi- or unskilled manual class membership in 1991 Permission granted from International Journal of Epidemiology, 31(2), Mel Bartley and Ian Plewis, Accumulated labour market disadvantage and limiting long term illness, pp , Copyright 2005 with permission from Oxford University Press.

“Labour market disadvantage score” Semi or unskilled manual class 1971, 1981, 1991 = 1 point each Unemployed 1971, 1981 = 1 point each Range = Total 0 = never unemployed, always in skilled or non manual work Total 5 = Always in semi or unskilled manual work, unemployed in 1971 and 1981

Odds of limiting long standing illness in 1991 by accumulated labour market disadvantage Men aged in 1991 Permission granted from International Journal of Epidemiology, 31(2), Mel Bartley and Ian Plewis, Accumulated labour market disadvantage and limiting long term illness, pp , Copyright 2005 with permission from Oxford University Press.

Life-course explanations for health inequality Health inequality is the result of processes that operate over time in the life of the individual Consistent with the observation that inequality takes the form of a ‘gradient’

More recently developed approaches “Neo-material” “Life-course political economy”: social environments as sources of capability and resilience

“Neo-material explanation” Originates in the debate on income distribution and overall population health

Why might income inequality damage health and well-being? “Income inequality” may influence aspects of social relationships: relative importance of domination versus mutual support It might be acting as an indicator of other social institutions such as welfare, education, housing, transport.

The ‘psychosocial interpretation’: Social relationships vary with income inequality Social trust Social distance Mutual support Aggression and violence

The ‘neo-material’ explanation: Social policies vary with income inequality Coverage of social insurance Generosity of welfare provision for parents, carers, unemployed Percent of GDP devoted to education and public health (not necessarily acute medicine) Quality of housing for lower income families

The ‘capability’ interpretation Social environment influences individual development & resilience through quality of relationships over time Social and economic policies influence adequacy of individual resources for health and quality of life = ‘capability’

Need for a ‘life course political economy’ of health inequality? 1. The causes of major trends in population health are still poorly understood 2. Economic environment relates to health in the context of the life course; 3. Effects of social policies differ between stages of the life course (childhood, youth, maturity, older age).